Provider Demographics
NPI:1598659112
Name:OTIS, ANTHONY (MSW)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:OTIS
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2822 PICKETT RD APT 154
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-9307
Mailing Address - Country:US
Mailing Address - Phone:757-713-1296
Mailing Address - Fax:
Practice Address - Street 1:4410 CLAIBORNE SQ E STE 334
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2074
Practice Address - Country:US
Practice Address - Phone:757-713-1296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-06
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040062601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical